Features February 2008 Issue

Elbow Replacement Lasts Longer, but Isn’t for Everyone

Despite advances in surgical procedures, elbow replacement is still recommended for only the most severe degenerative problems.

Joint-replacement surgery comes with no guarantees.

Doctors cannot promise that your new hip or knee will last you the rest of your life. And itís no different for elbow arthroplasty, or total elbow-replacement surgery, says Jeffrey Lawton, MD, an orthopaedic surgeon at Cleveland Clinic.

An elbow implant consists of two metal stems that are connected to create a hinge and secured by a metal locking pin. Each stem is inserted into each of the prepared bone canals. A special cement is injected into the canals to hold the stems in place.

But doctors have made great strides in replacement surgery in recent years, and while they still canít make guarantees, they do say the longevity of replacements is improving.

Patients today, Dr. Lawton says, can expect their new elbow joint to last longer than those used in the past, when elbow replacements tended to wear out after only five to seven years. Thanks to advances in materials and design, patients now can expect their new elbows to last at least a decade.

"I tell patients they can expect them to last 10 to 12 years," Dr. Lawton says. "But everyone is different. One patient has had hers for 18 yearsóand sheís still doing great."

The widespread use of elbow-replacement surgery started in the 1980s, more than a decade after doctors started regularly performing hip- and knee-replacement surgeries. Even today, the number of elbow-replacement surgeries performed annually in the U.S. is dwarfed by the 500,000-plus knee replacements and 400,000-plus hip replacements performed every year.

Elbow-replacement surgery differs in another aspect, too, Dr. Lawton says. The bones in the hips and knees are larger, which allows the surgeon to use thicker, sturdier replacement parts. In contrast, the ulna bone that makes up the forearm is fairly slender, which requires the use of a slender implant and a slender cement mantle to hold the replacement parts, he explains. The whole design is thus more fragile.

Indeed, a study published in the September 2007 issue of the German orthopaedics journal Der Orthopšde found that "elbow arthroplasty requires demanding surgery" and is associated with a comparatively high rate of complications, including dislocations that can cause functional impairments that require a second surgery to correct.

Consider Other Options First

Patients with rheumatoid arthritis make up the largest group of patients, says Dr. Lawton, because their disease can cause significant degeneration of the joint. Elderly patients who have suffered a severe break in the bones in and around the elbow make up the second-largest group. Studies have shown that these patients tend to do better with replacement surgery vs. treatment for the fractures, he says.

Few patients with osteoarthritis qualify for elbow replacements; joint erosion, or the normal wear-and-tear on joints that comes with age, says Dr. Lawton, is not a condition for which elbow replacement is suited. "Replacement surgery puts significant limits on a patientís new elbow," he says. "Just because the arthritis in your elbow wonít allow you to play golf or pull out fence posts doesnít mean you should have this surgery."

No one should consider elbow replacement as a first option for dealing with a degenerative joint, Dr. Lawton says.

One alternative surgical option is debridement, in which the surgeon removes debris such as bone spurs or loose pieces of cartilage on and around the joint. A patient might need a more aggressive procedure called synovectomy, in which the surgeon removes inflamed synovial tissue, or joint lining, around the elbow.

What Surgery Entails

Although newer medications used to treat rheumatoid arthritis are reducing the need for these surgeries, some patients reach the point where the deterioration in their elbow as well as the corresponding pain warrant joint-replacement surgery.

Although the elbow is much smaller than the hip and knee, elbow arthroplasty is still an invasive procedureó"about as invasive as knee or hip joint-replacement surgery," Dr. Lawton says.

Two types of replacement options are available. One is a semi-constrained, or linked, prosthesis in which the artificial joint has two components (ulnar and humeral) with a modified hinge between them. The second is a non-constrained replacement, which is similar to a knee replacement and requires the support of the bones surrounding the elbow, Dr. Lawson explains.

Most replacement surgeries use the linked prosthesis, but for patients who have less extensive bone and joint damage, non-constrained replacement allows them to carry more weight while requiring less post-op physical therapy.

Patients can expect the surgery itself to last two to three hours, and they should plan to stay one to two nights in the hospital. Patients can also expect to start using their new joints shortly after surgery. But while doctors encourage their patients to start moving their new joints soon after the procedure, the patientsí elbows are usually splinted to allow the soft tissues around the joint to begin healing.

Benefits of Surgery

Dr. Lawton says he often sees patients who have unrealistic expectations about replacement surgery. Patients frequently think theyíll regain much of their original strength and mobility, and thatís just not possible. In fact, itís recommended that patients lift no more than five pounds after they have undergone elbow-replacement surgery.

"The two greatest benefits of elbow replacement are increased range of motion and decreased pain," he says. "These are not arms you can use to do push-ups, but if you have a very stiff, very painful elbow, replacement is an appropriate procedure."

Thatís why patient selection is important, Dr. Lawton says.

He recalls one patient who had injured her elbow at the age of 19 and then later developed rheumatoid arthritis. As a result of the two events, she couldnít move her elbow for 35 years. She then underwent replacement surgery and regained 90 percent range of motion in her damaged arm. "Her elbow isnít necessarily pain-free, but itís much more comfortable and gives her back the use of her arm," says Dr. Lawton.

But few people find themselves in such circumstances. In fact, Dr. Lawton advises eight out of every 10 patients not to have the procedure. The surgery, he notes, is not for people who find that a stiff elbow makes it impossible for them to play golf, or swing a hammer, or lift grocery bags.

"The key thing for people to know is that there are significant limitations with this surgery," he says. "Elbow replacement offers tremendous advantages for patients whose lifestyles fit within its limitationsóbut for the wrong patient, itís the wrong thing to do."